ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B
1. A client has been prescribed lithium for bipolar disorder. Which of the following should the nurse teach the client to monitor for signs of toxicity?
- A. Nausea and vomiting
- B. Increased urination
- C. Tremors
- D. Blurred vision
Correct answer: C
Rationale: The correct answer is C: Tremors. Lithium toxicity can present with symptoms such as tremors, nausea, and blurred vision. Tremors are a common early sign of lithium toxicity and should be monitored closely. While nausea and vomiting can also occur with lithium toxicity, tremors are more specific to lithium toxicity. Increased urination is not typically associated with lithium toxicity, and blurred vision is less common compared to tremors in this context.
2. A client is found on the floor of their room experiencing a seizure. Which action is the nurse's priority?
- A. Restrain the client
- B. Place the client on their side with their head forward
- C. Perform a neurological assessment
- D. Monitor the client's vitals every 2 minutes
Correct answer: B
Rationale: During a seizure, the priority action for the nurse is to place the client on their side with their head forward. This position helps maintain an open airway and prevents aspiration of fluids or secretions. Restraint should never be used during a seizure as it can cause harm to the client. Performing a neurological assessment is important but not the immediate priority during an active seizure. While monitoring vitals is essential, ensuring the client's airway is clear takes precedence.
3. A nurse is reviewing dietary assessment findings for a client who is Jewish and observes kosher dietary practices. Which of the following behaviors should the nurse expect to find?
- A. Leavened bread may be eaten during Passover
- B. Shellfish is commonly consumed in the diet
- C. Meat and dairy products are eaten separately
- D. Fasting from meat occurs during Hanukkah
Correct answer: C
Rationale: The correct answer is C. According to kosher dietary laws, meat and dairy products cannot be consumed together. This practice stems from the prohibition in Jewish law against cooking a young animal in its mother's milk. Therefore, the nurse should expect to find that meat and dairy products are eaten separately. Choices A, B, and D are incorrect. Leavened bread is not eaten during Passover (Choice A), shellfish is not consumed in the kosher diet (Choice B), and fasting from meat does not occur during Hanukkah (Choice D).
4. A client has been prescribed nitroglycerin for chest pain. Which of the following should the nurse include in the teaching?
- A. Take one tablet every hour for chest pain.
- B. Store nitroglycerin tablets in a cool, dark place.
- C. Take nitroglycerin with food to reduce stomach upset.
- D. Take nitroglycerin with an antacid to prevent heartburn.
Correct answer: B
Rationale: The correct answer is B. Nitroglycerin tablets should be stored in a cool, dark place to maintain their potency. Storing them correctly ensures that they remain effective when needed. Choices A, C, and D are incorrect. Taking one tablet every hour is not the correct dosing regimen for nitroglycerin. Nitroglycerin is usually taken as needed at the onset of chest pain, with specific instructions from the healthcare provider. Taking nitroglycerin with food or antacids is not necessary, as it is usually placed under the tongue for rapid absorption.
5. A nurse is teaching a client who is taking prednisone about the adverse effects of this medication. Which of the following should the nurse emphasize?
- A. Weight gain
- B. Insomnia
- C. Hyperglycemia
- D. Hypertension
Correct answer: C
Rationale: The correct adverse effect of prednisone that the nurse should emphasize is hyperglycemia. Prednisone is known to increase blood sugar levels, leading to hyperglycemia. While weight gain and other metabolic changes are possible side effects, hyperglycemia is a more critical concern due to the risk of uncontrolled blood sugar levels and its impact on overall health. Insomnia and hypertension are not typically associated with prednisone use, making them less relevant to emphasize during client education.
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